The New York Times published a joke in December 1942 about a soldier writing home to his mother from camp. “The food in this camp is absolute poison. And such small portions.” The Dean of the Harvard Medical School, Jeffrey S. Flier, writes that the same thing is true about health care “reform”: it will take everything that is bad about the current US system and give patients more of it. In the process, it will also take everything that is good about the status quo and give people less of it in the future. The bad news is that certain food items in the camp will remain “absolute poison”; the good news is that it will be available in really generous portions. Flier analyzes the current system’s problems:
Our health-care system suffers from problems of cost, access and quality, and needs major reform. Tax policy drives employment-based insurance; this begets overinsurance and drives costs upward while creating inequities for the unemployed and self-employed. A regulatory morass limits innovation. And deep flaws in Medicare and Medicaid drive spending without optimizing care. …
In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it. Likewise, nearly all agree that the legislation would do little or nothing to improve quality or change health-care’s dysfunctional delivery system. The system we have now promotes fragmented care and makes it more difficult than it should be to assess outcomes and patient satisfaction. The true costs of health care are disguised, competition based on price and quality are almost impossible, and patients lose their ability to be the ultimate judges of value.
The solution: provide more of the same defects. Flier asserts that the major problem with the current system is that many parts of it are excessively regulated and dominated by monopolies. Other critics have also called it overlawyered. But for many advocates of “reform” the real problem is different: there aren’t enough regulations; not enough special interests, not enough lawyers for them. The answer to the current difficulties is to increase the size of the portions. Dr. Flier says the result will be more expensive health care and fewer and less innovative therapies. Flier tells the public to rig for depth charges, and adds, “we should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead.” But of course we should, how would you otherwise get them to go down it?
Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern.
In effect, while the legislation would enhance access to insurance, the trade-off would be an accelerated crisis of health-care costs and perpetuation of the current dysfunctional system—now with many more participants. This will make an eventual solution even more difficult. Ultimately, our capacity to innovate and develop new therapies would suffer most of all. … We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead.
Keeping the electorate ignorant may after all be the point. Just as institutional food service is often run for the benefit of the cooks and not the diners, institutional health care may actually be intended to serve the System and not the patients. If the whole point of the exercise was to take money and choice away from one set of actors and transfer it to another, the “reform” effort could hardly be bettered. Reform certainly gives the System more power. Britain’s NHS provides a preview.
The Daily Mail says the British government’s health rationing body, NICE, has decided that 18,000 pounds is too much to pay for extending a liver cancer patient’s life by six months.
Liver cancer sufferers are being condemned to an early death by being denied a new drug on the Health Service, campaigners warn. They criticised draft guidance that will effectively ban the drug sorafenib – which is routinely used in every other country where it is licensed.
Trials show the drug, which costs £36,000 a year, can increase survival by around six months for patients who have run out of options. The Government’s rationing body, the National Institute for Health and Clinical Excellence (Nice) said the overall cost was ‘simply too high’ to justify the ‘benefit to patients’.
But which costs? The Daily Telegraph says data submitted by NICE “shows that supplying the drug to the 600 to 700 people with advanced liver cancer would cost a total of £7.7m. … Nice has decided that the £7.7m would be better spent elsewhere in the NHS, that could be on other cancer treatments, or heart transplants, on intensive care facilties for premature babies, or hip replacements.” Anyone with a calculator can easily determine that the average cost of extending a British liver patient’s cancer patient’s life comes to something more than 130 pounds per day. Not that cheap, but on the other hand less than many motels charge for a day’s lodging. The Daily Mail argues that the problem really isn’t cost — the real problem is the diffcult of setting up a new bureaucracy to meet the needs of the relatively small and politically underpowered constituency of terminal liver cancer patients.
The problem for campaigners is that liver cancer is not as high profile as breast cancer. This is partly down to the fact that fewer people get cancer of the liver than are diagnosed with breast cancer – around 3,000 a year compared with 45,000.
But that is not the whole story. Breast cancer has two charities fighting its corner – Breakthrough Breast Cancer and Breast Cancer Care – both of which attract millions of pounds in donations, and help boost the profile. Other cancers tend to fade into the background. There is, for example, still no prostate cancer screening programme that compares to the major screening programme for breast cancer.
And these practices may already be in America. The Washington Post describes what may be the first of many actions by a government appointed “task force”.
Women in their 40s should stop routinely having annual mammograms and older women should cut back to one scheduled exam every other year, an influential federal task force has concluded, challenging the use of one of the most common medical tests. In its first reevaluation of breast cancer screening since 2002, the independent government-appointed panel recommended the changes, citing evidence that the potential harm to women having annual exams beginning at age 40 outweighs the benefit.
Coming amid a highly charged national debate over health-care reform and simmering suspicions about the possibility of rationing medical services, the recommendations immediately became enveloped in controversy. …
the American Cancer Society, the American College of Radiology and other experts condemned the change, saying the benefits of routine mammography have been clearly demonstrated and play a key role in reducing the number of mastectomies and the death toll from one of the most common cancers.
“Tens of thousands of lives are being saved by mammography screening, and these idiots want to do away with it,” said Daniel B. Kopans, a radiology professor at Harvard Medical School. “It’s crazy — unethical, really.”
With politics in the picture it is not inconceivable that high profile or politically correct diseases will get more dollars; that some patients will be more equal than others. Dean Flier says that bureaucracy will inevitably set “targets” and “averages” and establish themselves to supervise it. The pixel pushers and lawyers would grow in number, almost outpacing the bacteria they are charged to combat. What would decline the most of all, according to Flier, was innovation, an area in which the Cato Institute says the US currently leads the world. “In three of the four general categories of innovation … — basic science, diagnostics, and therapeutics — the United States has contributed more than any other country, and in some cases, more than all other countries combined.”
But the best prism through which to view these developments isn’t ethics, as Dr. Kopans believes. It is our old friend the principal-agent problem. When the actual market for health care “reform” is understood, its outputs — less care, higher costs, more bureaucracy, less innovation — are readily understood. Monopoly rents and government jobs are the natural outputs of a system whose main customers are lawyers, insurance companies, bureaucrats, doctors and only patients as an afterthrough. The patients will have the smallest market power. And after the “reform” is completed they may have little or none at all, which leaves the resources open for division among the remaining players. As long as the patient had some way of influencing the agent, like his doctor for example, the link between the sick person and the system was direct and responded somewhat to demand. In a completely bureaucratized system the patient’s interests will be represented only diffusely, through giant boards, task forces, insurance companies, lawyers and bodies like NICE. And in the nature of things his agents may begin to operate the system entirely for their own benefit. The patient will become the forgotten principal, a pathetic dying thing to be trotted out in the service of this or that agenda, but useless otherwise.
Once the relative market power of parties under the “reformed” system is understood, everything follows directly. As in every industry dominated by monopolies, innovation will shrivel. The medical equivalent of more chrome and styling will be trotted out each year over the same old chassis. Lawyers and special interests will gorge themselves at the trough. Bureaucracies will get bigger. Hospital wards may decline in size but forms will multiply like a contagion. Britain’s NHS boast that “only the Chinese People’s Liberation Army, the Wal-Mart supermarket chain and the Indian Railways directly employ more people” speaks volumes. But of the patient? Well if you’ve got terminal liver cancer in the UK, then a hundred and thirty odd pounds a day may be too much to keep you alive, not because the money isn’t available, but because it’s bureaucratically unobtainable. When you aim to be like the Chinese People’s Liberation Army, then some recruit is bound to write to mother and say, “the food in this camp is absolute poison. And such small portions.”
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Not only is it unobtainable but IIRC (and I will happily accept correction) even if you have the 130 quid a day to pay for the drug yourself and you do you’re out of the NHS for all other purposes as well. We’ll provide care for you, as long as you die when you’re supposed to do so.
There is some rationale in this, people might be diagnosed with a treatable illness, object to conventional therapy and choose some flavor of snake oil for months or years until they present for treatment of the later stages of an advanced illness on the public’s dime. That would seem to be a problem, but giving people with a terminal disease a shot at another six months IF they give up all other care and the doctors they’ve seen to this point…that just seems mean.
There is a deliberate population-centric assessment in the USPSTF recommendation that people in the US find so galling, though I doubt many of them would articulate it as such. The needs of the many outweigh the needs of the few is fine logic, but it ignores the fact that about 2/3 of eligible women already get regular screening mammograms. The point is not to screen more women under these guidelines, the point seems to be solely to save money by NOT screening as often as has been done in the past. I have seen several women remark on the seeming paternalism of wanting to ‘avoid anxiety’ as the justification for not looking for cancer in younger women — despite the statistics showing that younger women are biopsied less often than older women. It’s odd to find concern about anxiety being a reason now to shave costs, after two decades of increasingly shrill warnings about breast cancer and the one-in-eight statistic of lifetime incidence of breast cancer being used to anxiety women into the mammography room.
It is further interesting that the political implications of the government appearing to force population-centric solutions are not lost on the Obama Administration, or at least not on the HHS Secretary, who pulled an Emily Litella and suggested that everyone stick with their current screening regimen. Maybe this is because it is a politically-sensitive time, with the USPSTF’s seemingly insensitive computer modeling an example of what there is to look forward to. Maybe it’s because Secretary Sebelius got an earful from friends and relatives diagnosed with breast cancer in their forties who understand how important screening was for them.
Yes, our healthcare system is expensive — but it is patient focused rather than population focused, and I’m not sure that’s a bad thing. It is not a bad thing when patients with private insurance are paying for their own care, either directly or indirectly through risk pooling. It is certainly a bad thing when the patient focus leads to gaming the system, there was an article in the WSJ about people in Massachusetts who regularly game the system by buying health insurance only long enough to treat their condition, shorting the risk pool and circumventing the ‘everybody pays’ egalitarianism that was the intent of the Massachusetts plan. Why a failing Massachusetts plan is now the model for a national system that is highly likely to fail is not spelled out by supporters of the current system.
Dr. Flier’s article has its most important lines at the end — this is not THE solution, even the advocates of the current bill understand that it will not make healthcare cheaper, and already have a plan to do that. It is a plan they are not discussing or disclosing at this time, because the current plan is not meant to succeed. It is meant to fail, and create the need for a follow-on plan that will be much larger in scope and much more like the NHS.
What this really boils down to is the simple question; Do you want to trust the government with your future?
Consider for a second the government’s track record with big projects; Post Office (going bankrupt), Interstate Highway system (great idea, now falling into ruins), Fannie Mae-Freddy Mac (gone belly-up), FHA (going belly up), War on Poverty (costs in the trillions, no progress made), War on Drugs (see War on Poverty), Education Reform….the list goes on. The only objective the the governement has met (in large part) is defense, and over the last ten-twenty years that has been crumbling as well.
One really has to ask oneself if you want the amoral, larcenous thugs in DC “looking after” your well-being.
I for one do not.
This is why I watch what I eat and exercise regularly. Staying outside of the system is the only sane option.
In brief: Yes.
As usual Yes Minister was ahead of us, “The Compassionate Society.”
A couple of days ago I went down to the VA medical center. My eyes have been giving me some trouble and I fear it is getting worse. Some years ago I had Lasik and it worked great. A year ago, after the bullets did not hit the target at FLETC, I had the surgeon who did the job take a look and he said that physically everything was good. Since my focus seems to slip on occasion now I fear that I might have sustained an injury in training that is manifesting itself and could at worst case produce an aneurysm. Of course it could just be age and dog hair or a cold in my system.
At the VA in Manhattan I was seen remarkably fast by the intake nurse. After waiting less than half an hour she listened to me, took my BP and weight, gave me a flu shot, and asked me a series of questions that the VA mandates “Were you ever sexually assaulted on active duty?” That made me mention my last active duty CO’s Fitness Report. “Do you have any thoughts of depression or suicide?” That got me to mention that I would rather give others reason to have such thoughts than have them myself. The nurse loved me. A nice young woman was the Dr who took a look and checked reflexes and then told me to go up to Opthalmology, where they would look at me and decide if I should go to Neuro. When I got upstairs the clerk at the desk, if you open the dictionary to GS-5 you will see his portrait, asked me my name. I spelled out my name for him and added my last 5 as he looked up the referral in the computer. His phone rang and he juggled a personal call and my records. He got it wrong and I repeated the process. He asked me my name again and I spelled it. He then said “No, your name is XXX isn’t it? That is your name.” This was clearly a bully who got his jollies in a very dull job by asserting authority over the Veterans who must come to him before they can see a physician. He said my record said “routine” and I would have to make an appointment. When I said the Dr had indicated that she expected me to be seen today he then said that there were two notations and he disappeared into the back and came out a minute later and said I was to come back for an appointment in December. Arguing the point would clearly only result in terrible things happening to my records. After making the appointment I went back downstairs and informed the nurse at intake and she promised to inform the referring Dr.
The system is stuffed with people like the clerk. The more that government gets to influence healthcare the more it will resemble the VA. Most of the people are in fact caring, the professional staff who are part of the NYU hospitals are excellent and caring. The problem is that adding government to the mix, at the top end with lawyers and at the bottom end with clerks, only makes things worse.
OT, I just did a thousand words on Obama’s continuing slide in the polls, on my blog.
1. Darren:
Your point about population-centric models hits the nail on the head. Each patient (being an individual person as opposed to a series of statistical values) wants to be treated as an individual. Socialists, due to their adherence on Marxist class concepts, do not tend to think of “persons” only of “populations” or “classes” (read that as Proles). Historically socialists are quite happy to generate huge body-counts on their road to Utopia. That is one of the reasons they are so frightening.
With politics in the picture it is not inconceivable that high profile or politically correct diseases will get more dollars; that some patients will be more equal than others. Dean Flier says that bureaucracy will inevitably set “targets” and “averages” and establish themselves to supervise it.
This has already been true in the U.S. to some extent, and in part due to allocation of federal dollars based on the power of the lobbying efforts. The new healthcare bill will exponentially aggravate this problem.
When you aim to be like the Chinese People’s Liberation Army, then some recruit is bound to write to mother and say, “the food in this camp is absolute poison. And such small portions.
The sad thing about that analogy is that the CPLA no longer wants to be like the CPLA. That goes to prove that the NHS model is indeed slow, cumbersome, near paralysis, and unable to innovate.
Incidentally, the Pelosicare bill is 1975 pages longer than the U.S. Constitution, amendments and all.
I’ve got to stand up for the USPSTF. For a long time now they’ve been almost the only disinterested, evidence-based group to take an objective look at whether something really works or not. They have very often shown that customary modes (read: ‘traditions’) of treatment are no better than placebo, sometimes worse.
Americans are over-doctored and overtreated and often given new, expensive medicines when older, cheaper ones are equal or better. Now: who would want that to continue? And, frankly, the American Cancer Society and radiologists are hardly disinterested parties in this matter of mammograms.
If the evidence doesn’t show something is effective, why do it? If something else is cheaper and equally effective, why not change? The question comes down to whose ox is being gored.
I have relied on the USPSTF’s information for a long time–the Cochran studies are another excellent source as to what really works. The medical journal American Family Physician (now AFP) regularly publishes data from these sources for their subscribers.
Those truly interested in knowing how modern American medicine really is should learn more about the USPSTF and the Cochran organization and also read “Overdo$ed America” and recent books by Marcia Angell and Jerome Kasserer, both former editors of the New England Journal of Medicine. You will be profoundly enlightened. Fact is, doctors commonly give their patients far more treatment than they use on their own families.
So, to return: if fewer mammograms are just as good, what is the justification (and where is the evidence) for continuing the present practice? And if, secondarily, money is saved why is that bad?
Gordon:
You missed the main points by a very wide margin: This is not so much about whether or not a treatment is needed. It’s about government mandates dictating what is and is not needed. Bureaucracies have a consistent habit of taking good intentions and twisting them into knots, and perversely redirecting those intentions towards the proverbial ‘Road to Hell.’
I think we’d rather have doctors and thir better-informed patients making those decisions. As to the breast care study: the HHS secretary publicly disavowed its suggestions.
If mammograms for women under 40 are now being advised against, I wonder how long it will be before living organ donation is completely cut out….
LoTM, sorry to read of your shooting eye and care issues. Age is messing with my vision and I always notice it the most afield.
When I got upstairs the clerk at the desk, if you open the dictionary to GS-5 you will see his portrait, asked me my name.
LOTM. I deal with such people too. Personally, I think electrodes should be attached to their tiny parts, so that a charge surges towards them when an encephalogram machine registers hostile thoughts in their brains. I’m assuming they have brains, of course.
Gordon,
You said if fewer mammograms are just as good, but the USPSTF did not say that. They said that fewer mammograms are more efficient. The difference is a few thousand cancers a year that could be found & treated in earlier stages, primarily in younger women. Compared to a background of just under 200,000 breast cancers a year, that’s not very many. For those few thousand women and their families, that’s quite a lot.
Only 62% of radiologists read mammograms, and few really like it because of the insane liability associated with mammography. The radiologists who read mammograms are not “disinterested” because they know what breast cancer looks like, interact and biopsy patients with potential malignancy and have a vested interest in finding it at the earliest possible moment. As one of those non-disinterested radiologists, I can tell you that if you switch to q2y screening my recall rate will increase, because now you’re telling me I have to say that nothing is going to go wonky for 24 months rather than 12. I can’t make enough doing workups and biopsies to compensate for being wrong just once, so where does my self-interest lie?
The other cost savings is in cancers the USPSTF believes should not be treated. DCIS is the earliest stage of breast cancer, left untreated between 30 and 50% of DCIS will progress to invasive breast cancer. A population-based system would say that up to 70% of DCIS does not need to be resected, because the patient will die from something else before the cancer becomes invasive. An actual solution would be some combination of genetic and proteomic assay that could give the risk of progression from a biopsy of DCIS and allow a woman a better choice than whether to play Russian Roulette with two or three chambers loaded. There is no such assay at present time, and there is unlikely to be one because the odds and the bottom line favor leaving DCIS in place if a population-centric decision model based on cost is the only one utilized. If the insurer will not pay for resection, then why develop a tool that indicates if resection is needed?
Again — if the number of screening mammography slots in the nation were fixed at an upper bound that could not address every woman over 40 who wanted one, then a population-centric risk stratification would seem to be in order. But given that the 40-80 year-old population is looking at a 63% reduction in screening mammograms (assuming equal numbers in each decade, none for the 40-49, half the screenings in the 50-59 and 60-69 populations, and a quarter in the 70-79 population), we may see enough mammography screening facility closings to make that population-centric recommendation come to pass if the USPSTF recommendations are followed.
Joe buzz,
Mammos are not being advised for women under 50. Unless you listen to the HHS Secretary, who says fire-at-will at age 40.
Now then my man, what have we here, the doc said with a smile
Just what can I do for you today?
The man said firm and brisk and clear, I’ve had this little while
A problem that won’t seem to go away
Aha, I see, the doctor mused, while glancing at his chart
I see you have a cancer on your hands
There is a drug that may be used, and yes, I cross my heart
I’d use it now, except it’s just for glands
And so I fear there’s naught be done, the government says no
Your liver cancer must now run its course
If not for that you’d live another one, six months or so
But government is still the money source
I see the man said getting up, I know I’m not the first
Who wants to live his life a bit too long
The pain you know’s not letting up, this liver is the worst
And living six months longer is no song
It’s just that I would like to do a few things that I’d missed
Like climbing Mount McKinley and the like
And there may still be one or two sweet girls I have not kissed
And crossing old Death Valley on my bike
I know the government knows best, knows what is best for me
I thank my lucky stars that Harry Reid
And Nancy and Barack and all the rest can clearly see
That what they want is what we mortals need
So I’ll go home and pack my bags and get my good suit cleaned
And try to smile and hope for all the best
And I will know that my toe tags will read Death Panel Screened
Before they sent me to eternal rest
Gordon misses the mark. This strikes me more as one of those
1) “Of course we would never suggest such a position, and anyone who says we would is a lying racist”
and after passage of time
2) “We’re not directly advocating such a position, but it is worth further investigation”
and after further passage of time
3) “Anyone who who opposes this position is a lying racist motivated solely by greed”
The quality of all thing governmental varies inversely with the size of the program. I am sure that the poor soldier’s food started off as quality ingedients but having passed through multiple layers of bureaucratic attention it is now nearly poisonous and in tiny portions.
The most telling aspect of the entire game is that not one of the Beltway trolls have committed to being “covered” by this program. None of them have even suggested that the current platinum-and-diamond plated coverage they enjoy be dropped as a show of good faith.
Things that make you say hmmmmmmmm.
The Agency problem is solved by violence. This means practically inviting, begging, people to use violence (or hire it out) on their behalf. Carry out violence and then credibly threaten more unless group interests for members are met.
This is why Nidal Hassan was promoted, why Toby Emmerich declined to film the destruction of the Kabaa, why Muslim terror is never mentioned, and why Muslims are in the front of the line for special, better treatment than anyone else.
Second in line are Blacks, who also carry out and threaten violence (see Al Sharpton and the Crown Heights Riots, the arson of the Jewish owned retail establishment), and are not shy (see the New Black Panther Party and Eric Holder) about exercising Black violence on behalf of Black interests against Whites and Asians (see Tookie Williams victim list).
Third in line are Hispanics, who employ violence, on a lesser extent than Blacks, but do indeed use it and find no come-back (I am thinking principally of La Raza rallies for illegal immigration, May Day beat-downs of Whites, etc.)
This is the system: it rewards those who intimidate by violence and punishes those who do not and get sent to the back of the line for last place in divying out goods. Be they justice, or medical care.
THEREFORE: since Health “reform” is a done-deal, with Dems happy to trade seats for the patronage and punishment of the White majority (which they loathe), what we will see in the US is the creation of “vigilante” or “regulator” violence, in the way of the San Francisco “Committee of Vigilance.” America is bigger, with a more spread out population, and harder to police than Britain, explaining why Brits simply were cowed like sheep (no tyranny of time and distance for the authorities) and Violence will be expected here.
If a few folks like the loathesome Eric Rudolph or Timothy McVeigh, of evil memory, can commit violence at a high level, what happens when most White Americans find their mother, grandmother, sister, or wife are sentenced to death so that an illegal alien from Mexico can get free health care?
The answer is, violence. Particularly for those with little to lose. My guess is that the violence will aimed at both competing “front of the line groups” and the authorities, and it will be QUITE popular. Eric Rudolph it may be remembered had considerable help for YEARS in the Carolinas before finally being captured.
You don’t take the 87% of the population that has good health care, and screw them over, along racial-religious(Muslim vs. everyone else) lines and not get massive come-back. Even if Jessie Jackson says that you cannot be a Black Man and vote against “health care reform.”
LOTM, your clerk sounds rather like Eric Holder – officious, ignorant, and counterproductive, even if, who knows, well-intentioned.
Sorry to hear about your problems with there, but of course point taken that they are a harbinger of so many more to come.
The Agency problem is as old as mankind. Most of the time it is solved without recourse to violence. Social pressure, legal action, mass organizing, political campaigning serve for most cases. And even when violence is indicated, it is often possible to limit it to a few. When Eliot Ness went up against the bad guys, the Thompson stuttered out such rounds as it needed to speak, but it never had to sweep the street.
Now my problem with violence, apart from the fact that it’s kind of a drag is this. Why should we presume that people who act in a sheeplike manner today will suddenly become lions tomorrow? The idea that a majority will go placidly along until they snap has to answer the question: why won’t they keep trudging along like they always did?
Back in the day I discovered, or rather implemented the idea that resistance was a continuum. People just didn’t go from being Sad Sack one day to Audie Murphy the next. Therefore here’s the thing. Get people involved in nonviolent activity now. Get them politically active, contributing to candidates of their choice, working the phones, doing stuff now. Because if people can’t take a couple of days off from work or give up a weekend or two for things they ostensibly care for, the odds are that if a kind of fascism emerges one day, they’ll behave just as passively on day D and they did on day D-1.
The other reason legal action now is preferable to waiting for the boiler to blow is that real leaders emerge in action. The best predictor of who will lead best in a crisis are those who led best in a semi-crisis. The reason the Brits knew Winston would bear up against Hitler was that he bore up in the wilderness, when every man’s hand, both aristocratic and socialist, peacenik or warnik, was against him.
In general my suspicion for extreme solutions springs from this root. If not now, then when? If not now, then why bother?
Anton @ 11:16
Your comment got me to thinking. The sectors of our society that currently seem to be pushing socialism the strongest are the Liberal elite and the parasitic bottom. Those on the bottom naturally want socialism because they “need” more than they would ever want to produce, or feel themselves entitled to more because they Liberal elites tell them they are victims. The Liberal elite, meanwhile, includes some who are actually bright and could possibly be very productive. Why would they want a socialist state? Well, they do not see themselves as being the people who would be standing in the lines. Rather, they see themselves as being the ones who will run everything, and history shows that the people who run things don’t have to stand in line, regardless of the economic system. A capitalist system requires people to “earn it” if they are to avoid the lines. But socialism enables some to get in the position of running everything, not by earning it, but by getting political power largely from the lower class, by promising those gullible fools a utopia.
Those of us in the middle just want the other two groups to go away and leave us alone.
Wretchard, what do you make of the socialized healthcare system in Australia? Do you use the government service or a private one?
What I find real funny is proponents of health care reform often demonize the insurance industries — however, all they propose is more of the same. Another neat trick they resort to (or least used to) is find an insurance company that will deny coverage based on lifestyle. For example, no liver transplants for alchys and the like. However, far more such stories come out of nationalized health systems.
In addition, one thing free-marketeers point to is the difference between lasik & cosmetic surgery vs. all other care. Practitioners of lasik & cosmetic surgery can not count on third parties paying for their client’s procedures so they HAVE to minimize their prices and find ways to become more productive. I don’t want to rip on regular practitioners of medicine but there is no motivation there.
Anyone who thinks this medical grab is going to put the insurance companies out of business is ignorant. They will find ways to thrive, does anyone think DOD insurance programs are run by the Govt? Nope, it will be a whole lot more of the same.
Cap’ Rusty @ 19:
“The sectors of our society that currently seem to be pushing socialism the strongest are the Liberal elite and the parasitic bottom.”
Cap’n what about the many pharma companies backing Obamacare? Or all the giant investment corporations that eagerly lapped up the bailout money from TARP? What about the Savings and Loan Industry in 80s or Chrysler’s bail out under Reagan?
Does Goldman Sachs earn the billions it makes off it government connections? There are many forms of socialism and its strange that big business or Hayekian Socialism didn’t make your list.
Makes being “in the middle” a lot more complicated, doesn’t it?
Wretchard, what do you make of the socialized healthcare system in Australia? Do you use the government service or a private one?
I have both types of cover. The way it works is that your taxes pay for a certain amount of baseline care. Certain procedures are “bulk billable” — i.e. “free”. Other types of procedures cost more than the bulk billable rate. To get that higher rate of availability you buy private insurance which pays for a specified amount of the “gap” between what the government pays and what the doctor charges.
Suppose I go and have procedure X done and it costs $100. The government might kick in $40 and my insurer might kick in $50 and $10 is out of pocket. Now in general, they won’t let you just die. So if you are poor and without private health insurance, you can use a public hospital and get decent treatment there for essentially nothing. But it may not be the best treatment and it is certainly subject to some rationing.
Fortunately it is not subject (in my experience) to that much rationing because the Australian system is far less stressed than the NHS. Part of the reason it’s less stressed is because those who can afford private get it and leave the public system to the guys who are relatively poor. When you’re really old and dying, they might put you on palliative care if you’re in the public hospital, whereas you might have a better shot at survival if you were on private health cover.
So if you’re a working age person and need to have your teeth root cannaled and capped, you’re probably looking at $2,000 out of pocket per tooth unless you have private dental cover. But if you’re old and a state pensioner, you might get dentures for nothing. They might not fit too well, but you’ll get by.
The other variable is location. If you’re in the sticks, then the hospitals available, both public and private are often less well equipped than in the big urban areas.
The system has some real problems though. My understanding is that Australia has long since failed to produce enough doctors from local medical schools and were it not for immgrants from India, etc. there simply wouldn’t be enough GPs. You will notice too that many of the nurses or nursing aides are from places like the Philippines. Also, much of the physical plant of public hospitals is getting tattered. Put it this way, if there was a mass casualty attack in Sydney and 1,000 seriously wounded people needed help there would be a crisis. Not that any place wouldn’t be in crisis at such levels of casualty, but some parts of the system have been underreplaced for years. I’m no expert, but I think there is some amount of market failure.
What really saves Australia is that it is a country of about 20 million fairly prosperous, culturally homogenous people on a continent the size of the lower 48 without freezing winters and surrounded by thousands of miles of ocean. It’s the Lucky Country.
To say America could have the Australian system is to ignore many of those variables. America will have to solve its health care problems in an American way just because the institutional actors are different.
Do you like green egos and hams?
I do not like them, Uncle Sam-I-am.
Do you like them here or there?
I do not like them in Bellaire
I would not like ObamaCare,
I do not like green egos and hams.
Would you like them all in-house?
Would you like a govmint grouse?
I would not like a Mickey Mouse
Or a Dr. Lecter instead of Strauss.
Would you eat it as a Brachs,
Would you eat it, from a Federal fox?
Not a Brachs
Not a (lower case) fox.
Not in-house.
Not with bureau-mouse.
I would not eat them
here or in Bellaire.
I would not eat up Obamacare.
I would not eat green egos and hams.
I do not like them, Uncle Sam-I-am.
“A delectable blend of meat and gravies served tastefully over a shingle.” Only worse, much worse.
What is fun to watch is the growing opposition from a diverse bunch of groups to Obamacare, the brief mentions of maybe, possibly, we ought to sorta kinda look at tort reform comming from the administration. Yeah that will happen. I wish I had the life belts for rats concession in Washington.
IMHO the Democrats are going to end up short 4 senators after 2010 and the Republican conservatives are starting to talk about “If Obamacare passes in 2009/2010 how do we repeal it in 2011?”
This whole subject is nothing but propaganda fantasy.
The people have now shown how gullible and easily manipulated they are.
We are screwed.
Solon 2040 @ 22
You are right. What you site are examples of what Mussolini called Corporatism and the Progressives embraced as Fascism.
As you point out Goldman Sachs DOES earn its billions through government connections.
The profits of the 80′s were privatized and the losses were “socialized.”
Those on the top like to make agreements with the government because it keeps upstarts from getting into their businesses.
Of all the ideas being batted about, the one that sounds the best is the the Swiss model. Everybody has to buy insurance, but everybody can buy insurance. You can buy a basic model, or one with all the bells and whistles. The government subsidizes people who can’t afford insurance on their own. Compliance is maintained through the Swiss tax system.
Docs get squeezed on payments, but on the other hand they get paid pretty much all the time. There are copays to reduce overutilization and copays on pharmaceuticals as well.
Maybe they are piggybacking on the US as much as everyone else when it comes to medical innovation, but it sure sounds better than the bureaucratic monstrosity that the House & Senate are contemplating.
16. whiskey
It should surprise you little that I agree with almost every jot and tittle you wrote…
I have blogged on several blogs for six plus years and was thought by many as some kind of crazed, besotted madman for pointing out obvious things; such as you kill the enemy in wartime. And almost everything that the last thread had as major themes I had proposed years ago. The contributors have heard the tocsin and have taken a more aggressive position. That is good.
Now we are really into it and what you and I believe will happen I am more than certain will. We will have a civil war and it will be horrible, but I’m afraid unavoidable because too many citizens simply continued to allow or actually abet the government to grow until it has become our enemy, not our representative. Groups such as the Oath Takers are formed, other groups are formed and the thrust of them, although sub rosa at this time, is to be prepared when the government begins setting up gulags or some other illegitimate act is forced on the people; contrary to good peace and order. It becomes more apparent every day that we are going to have to fight our way back to the constitution. Let’s hope we can reconstitute it once the rubble has settled
I heard todat obama called a malingering onanist. Onan he can !!
“If Obamacare passes in 2009/2010 how do we repeal it in 2011?”
Once you give the uninsured something, you can’t un-give it to them. The best way to handle the health care problem is to put together a package that will actually solve some of the problems that Dean Flier and Dr Ambati once raised here. The problem with that is it will really be revolutionary in its own way. That will mean going up against a set of interests and will be an interesting political problem because I suspect many of those interests have supported both parties over the years.
Otherwise, the effort in 2010 will simply be a rollback of the Obamacare reform to some prior state which was none too good to start with. It’s like retreating from a climbing position you can’t advance from only to find yourself clinging by your fingernails to the lower ledge. In the end you’ll fall, but maybe some minutes later.
There is an alternative to the regulated insurance based model. It is called doing what has worked.
It relies on three (you can count on me) factors.
1. A healthy American economy that produces sufficient wealth to pay for services for the indigent.
2. An economic, legal and regulatory system that encourages private initiative, risk taking and the
development of new procedures and products.
3. A culture rooted in the essential goodness of the American people and a legal system that does not
discourage their natural generosity.
These three conditions produced a system that created vast wealth, raised living standards and encouraged charity sufficient to care for any who were unable to care for themselves. Americans are incredibly generous and take care of both their own and anyone in need. By comparison the Europeans we are being urged to emulate are cheap skinflints who would allow their own grandparents to die in an attic rather than interrupt a Summer vacation, and then complain that the government hadn’t done something about it.
Charity works. The government is determined to destroy it.
To be blogged under the title “Charity.”
Yes, but the current system is inflating the price of health care and/or insurance at an unsustainable rate, leaving more people uninsured or underinsured. This is an argument that Obama & company make now and again, that I have a lot of sympathy for. The Republican suggestions are along the lines you suggest – don’t burden the economy and make things worse, let companies sell policies across state lines, incentivize cost controls with HCAs and the like, and of course tort reform – apparently California is already in the lead for this, but it’s not like care is cheap here, even so I suppose we should do what we can.
The good news is that I think, per your #1, that we *do* have the money in the economy, and most of it already in the health care system, to do better than we are. That’s the kernel of truth in Obama’s suggesting “reforms”.
Unfortunately this kernel is overruled by the general incompetence Obama displays in actually getting anything done, in coming up with numbers that are better rather than worse than the status quo.
31. Lifeofthemind
It would be nice if ANY of your three examples could even come close to working, however the essential truth is this country is now so F’d up that your examples for what we could call normalcy (a word Warren G Harding made up) are inop.
I don’t have a better answer but I can and do recognise when a system is so perverted by those who control the power that there are no simple answers. The solution to our problems are not fixible by our traditional methods of simply voting. obama and his cronies have perverted that (Acorn etc) and I am sure are honing that perversion for the mid terms.
Why did the price of education, housing, health care, etc all go up?
The government mandated that money should be thrown at it.
You want medicine to be less expensive?
Repeal all laws, regulation, licenses’ and entitlements associated with the provision or consumption of medicine.
It is really that simple.
BTW – When I was a child there were probably 150 million people in the US without “Health Insurance”.
There was no “crisis”.
Close to twice that now have “Health Insurance” and we have a “crisis”.
More of the same is not the answer.
Dear President Obamus,
My poor mother Gaia is running a fever
some days, but then other times she has
the chills. Her temp varies
with the weather. Can you help
us feel on top of the world
by instituting ObamaCare?
Regards,
U. Rup and Hugo (Hu)
cc: D.N.C.
Green Eggs and Ham? I pass.
I chooses, (Chicago accent on) ‘Cheese and Onions’ by the Rutles.
http://www.youtube.com/watch?v=ePaHG6g7uFw
Do I need to spell it out?
LotM@31: Charity works. The government is determined to destroy it.
In the ‘no stone unturned’ category, even charity has been corrupted by bureaucratic influence. Note the fee structure of charitable organizations at the regional and national level. Then take a deep breath and follow the “development aid” that flows through the UN, as noted by others on numerous occasions.
Not that the basic thesis is flawed.
It’s just that I don’t donate anymore, except at a very local level. I can’t tell you how many supervisors have glared at me for refusing to make my United Way contribution.
The one structure I did like came from Sam Gary, the Colorado oilman, who created a charitable foundation funded by his company and run by a professional (Fern Portnoy) who carefully screened applicants to, not to put too fine a point on it, maximize the potential ROI. This model of charitable give-back has plausibility. The Bill and Melinda Gates Foundation, now merged with Warren Buffett, is another potential game-changer – long term – using targeted application of billions to eradicate disease as a first order priority.
I think, however, some care and caution is required to avoid the trap of ‘Creative Capitalism’ (google it), an initiative also being sponsored by Bill Gates; one that I find less exciting because it blends self-interest with communal interest in an arena that can potentially erode personal civil liberties in exchange for enhancement of “The Commons.” But that train has already left the station. Goldman “doing God’s work” Sachs is trying to polish a tarnished image by creating a fund to support small businesses who have not yet recovered from the 2008 meltdown. I lack the intellectual reach to know what will work, outside of my instincts, but I do acknowledge that there is no going back.
All I know is that when Rick Santelli’s lips move, I listen.
“The Agency problem is solved by violence. This means practically inviting, begging, people to use violence (or hire it out) on their behalf. Carry out violence and then credibly threaten more unless group interests for members are met.”
Well, I hope it won’t come to that. However imagine, in the not-so-distant future, a concerned family being informed by a Friendly Neighborhood ObamaCare Administrator, “Sorry, but your granny doesn’t meet our qualifications for a hip replacement. Here’s a pill. Take her home.” Shortly after which a family member returns to the hospital, sticks a pistol in the administrator’s face, and politely tells him, “Perhaps you’d like to reconsider your decision?”
When I was a young child in the 1950s, every summer thousands of kids nationwide caught polio and lived the rest of their shortened lives crippled or in iron lungs.
When my dad was a kid in the 1920s there were not even any antibiotics, child mortality and adult life expectancy were much worse than today. His parents died in their 50s, today with minimal care would probably live another thirty years in reasonably good health – my dad did.
People today in their forties to sixties get a 5-way CABG, are home in two days, and live another twenty years with nothing worse than the common ravages of age – which can be plenty bad enough, of course.
We spend a lot more on health care these days, but I guess we get something for it, too.
The thing is, the more medicine learns, the worse the actuarial process. When a policy just covers the one person in fifty who catches a rare bug and needs expensive treatment, policies are cheap. When it’s pretty sure that everyone will need hundreds of thousands of dollars of care before the end, the policy really turns into a time-payment plan, with a small bonus from the policy holders who are fatally hit by a truck and never get around to spending their hundred grand.
The arithmetic of the situation today is really what is intractable. And the moral questions, of just how much money should be spent on whom. It’s morally repugnant, it seems to me, that we have million-dollar treatments that can fix someone up, but if that someone is a sixty year old day-laborer versus a twenty year old billionaire – should that really determine who gets treatment? Well, it’s going to.
There are tough questions. It’s the failure to acknowledge them at all, to lie about them instead, and fudge the numbers absurdly, that pisses me off about Obama/Pelosi-care.
Richard, you really do need a more uplifting photo on this site, you look damn near beaten!
Wretchard,
re: Australia. Do employers offer health insurance as a benefit? Is health care taxed? (Are basic foodstuffs taxed?).
Are docs salaries supressed somehow? What else might explain the shortage?
The Lucky Country indeed. Does Australia (still) know this?
Richard, you really do need a more uplifting photo on this site, you look damn near beaten!
Pretty much feel that way too. Could do with a little more downtime though.
Wretchard –
You and I disagree because we come from different countries, where the ability to control violence by central authorities differs.
In Clinton’s America, the formula:
(Large, free, mobile, decent income population) X (very small disaffected lunatics) = Eric Rudolph and Tim McVeigh.
What was interesting about the former was the active assistance that the FBI asserted the people of North Carolina hill country gave Rudolph.
Now, take that same basic formula but change the second variable, i.e.:
(Large, highly mobile, decent income population that is highly dispersed) X (Massive hatred of government) = Far larger amounts of violent people than (McVeigh, Rudolph).
What ObamaCare does, SUDDENLY, is create a massive class of McVeigh/Rudolph losers, with no real desire to avoid violence. A man living a decent middle class life will certainly not go on jihad, he has a wife, kids, family to look after and care about. A man like McVeigh, or Rudolph (must I add, rootless men with no women in their lives, and no real ties to parents) can certainly fall into it.
Even when most were reasonably happy about America. The 1996 Olympic bombing came after all in good times. [Some security guard named Richard Jewel was falsely accused of it IRRC.]
Now, we suddenly have men who will be put bereft of lots of things: men “alone” when a spouse or parent dies, because of refused care, no family (kids) to think of. What then?
UNLIKE Britain, this is a highly mobile and dispersed society. Already the pattern of mobile serial killers (Richard Ramirez, the Railway killer, Ted Bundy) is established. As is the nightly carnage in inner cities. With occasional punctuations of violence by the McVeighs and Rudolphs. I think America is already well established as quite violent, and more openly violent than most nations because of it’s dispersed, chaotic, and spread out demographics with little “rootedness.”
This makes it vastly different than the Philippines and even from Australia (which has more “rootedness” and connections). America is home to the lonely man, the loner, in ways that reading Grant or Jackson’s biographies makes clear. [Jackson without the restraing influence of Rachel Jackson essentially sought to "kill" all his enemies.]
Suppose a man’s wife dies in her fifties because “cost saving measures” sought to make more money available for illegal aliens health care at her expense? He has no kids, no parents. No ties to keep on.
What is to keep him from killing as many “enemies” as he possibly can? After all, he can “cash out” and drive the interstate highway system, simply “target” various “enemies” in the fashion of Rudolph and McVeigh. But for an attentive State Trooper, McVeigh might not have been caught and Rudolph was on the lam for YEARS.
Multiply this by thousands.
I don’t like this — I shudder in horror at the carnage to come. Including many who like Rudolphs’ victims were innocent (the man was a monster). But I don’t see any reason why people who will suddenly be left with nothing and no ties, made into instant “loners without family and women” will not act like most men in that situation and look to “kill their way out of it.” Which is what most men do, historically. Machiavelli advised against making men suddenly poor, and this is exactly what it will do.
“With politics in the picture it is not inconceivable that high profile or politically correct diseases will get more dollars”
AIDS, for example?
wretchard,
“… you look damn near beaten!”
Pretty much feel that way too.
Be of good cheer. It may not be Reagan’s “Morning in America” but it is Spring in Oz.
Multitasking is hard but I could do with more of it. Not only am I out of work, and concerned about my eyesight, but today the State Unemployment sent me a drop dead letter. They determined that the part time temporary political work I did for the Bloomberg campaign did not pay me enough over a long enough period to qualify me for benefits. If I had simply extended my prior unemployment rather than taken the work I would have received thousands of dollars more. Now they canceled my old claim, disallowed my new one, and leave me with nothing.
To be blogged under the title “Other than that Mrs Lincoln …?”
I had my first experience with an IRS audit on my personal taxes today. Fortunately, I have a very thorough and organized tax preparer who has done my last several filings for me. So the two of us went into the audit well prepared and all went well.
However, the fellow doing the audit certainly did not have an accounting degree, and may not have even had a college degree. I give him credit that he was pleasant enough. Since all was in order on the items in question, he was able to manage through his check list of instructions such that all was cleared without event.
However….. It would not take much imagination to foreseen how things could have gone horribly wrong were we not organized and compliant, as this poor fellow really couldn’t follow the linear logic of this filing. Very easy to see this process going into the ditch if there was just the least bit of perceived tax evasion.
I kept trying to imagine this guy rationing health care to anyone in my family and I can’t believe it would be anything less than a full-on freak show.
LoTM, @5
The thing few realize is that unaccountable, bureaucratic government jobs with power, attract the sicko control freaks like flys. These jobs are the sicko’s dream job. This phenomenon is one of the main reasons why most bureaucracies are so inefficient and screwed up.
Hope you find a good job.
On the subject of mammograpy. My gynecologist, a woman, told me that over the past decade she has been seeing more and more breast cancer in young women in their twenties and thirties. So apparently there is no safety for young women in regard to breast cancer and they should not be excluded from having mammagraphies.
I am a family doc in the U.S. I have worked in NYC, NM, AK and CT in a variety of settings (Indian Health Service to private practice). We have a very complex and convoluted system that you never would have created from scratch. Highly recommend Paul Starr’s ‘The Social Transformation of American Medicine’ for any interested in how we got to this point. The system needs to be fixed to be sure, but as many more articulate than me have noted, the fix is in on fixing the health care system. I think collapse looms no matter what happens or doesn’t happen in Washington.
Wretchard, I find it interesting that no one is commenting on how Barack Obama and the Democratic Congress are probably going to inadvertently destroy the social welfare state that they are seeking to enlarge and extend. When Reagan tried to strangle the Federal government in debt, the liberals howled with outrage. But they are now running up a debt so huge that rather than finishing the work of FDR and LBJ they will likely bring on the collapse of medicare, social security and medicaid. The math and actuarial data seem plain as day to me, but they are so intoxicated by the victory almost won that they can’t see it. Like Hitler pushing to the Volga-blocks away from the final hard fought victory at Stalingrad- and missing the trap being laid for the 6th army by Zhukev’s massed armies.
Lord Acton,
Great Galloping Ghost of Godwin’s Law! You are right of course. The Greeks said it best, ὕβρις.
Today in my class for third year medical students and advanced practice nurses the topic was health care delivery. We compared health care systems in Japan, Taiwan, Switzerland, Germany, and the United Kingdom to the US. The material prepared by the higher-ups in the medical school was somewhat slanted toward Obamacare and toward the idea that the US system was very badly broken and needed a fundamental remake.
However, to my surprise, several of the students caught on to the problem of basing the medical system on efficiency or quality, and two of them wondered why their taxes should have to pay for people who deliberately neglect their own health.
As the discussion continued it appeared that there were a few key threads. One was whether availability of health care and utilization of health care were one continuous process or two separate ones. Was health care a right? And if so, could they name anything that wasn’t a right? We concluded that access to health care might be an essential ingredient to life and the pursuit of happiness but that it only had meaning when it was admixed with obligation.
Another thread was the tendency of the students to compare the current state of things with perfection. In that case reality always looks to be in need of major change. But the focus on major change seemed exciting to them while looking for the potential side effects and unintended consequences felt burdensome.
One student spoke of the general population as “morons” with regard to health care, and thus needed to be rescued from the error of their ways. This stimulated a consideration of the concept of “moral hazard” that none of them had ever heard of prior my introducing the term today.
The problem of increasing demand without increasing supply was something they hadn’t thought about much either. Their preferred solution was to subsidize medical school tuition and to require a year or two of national health service from graduates.
Finally, in the name of equality many students wanted everyone to have the exact same coverage, while others wanted everyone to have some sort of basic coverage while still allowing others to purchase a premium level of care. This was a very important sticking point for most of them.
In response I recounted the plot of a science fiction story of years ago by L. P. Hartley called “Facial Justice.” The basic idea was that since beautiful people had a built in advantage, and since it was very difficult to make ugly people beautiful, there was only one alternative to keep society equal. That was to disfigure people who were deemed to be too pretty. It strikes me that this is what Obamacare will do.
It certainly gave the students something to think about.
I am a doctor, on a salary at one of the alphabet agencies that you all have probably heard of. My field has nothing to do with mammography, but I can assure you that nearly all of the therapeutic interventions or screening/disease prevention maneuvers in modern medicine are vastly oversold to a credulous lay public. Not just mammography, but prostate cancer screening, cholesterol screening and meds, even Pap smears, vitamins, vaccines, and annual check-ups. Witness the serial vitamin fads (vitamin C, then vitamin E, then carotene, and now vitamin D is the new player). Keep in mind that when people were given large doses of carotene to prevent cancers, it actually increased the rate of cancer. As long as the proponents are sincere in their advocacy, all is well, regardless of the outcome.
Mammography certainly finds early cancers in some women, but in young women, it is technically not very good because the breast tissue is so much more dense than in older women. So extending mammography to women in their 20′s and 30′s is just not going to be very helpful. Furthermore, when the rate of a disease is low, the test you use had better be very specific (i.e., if the risk of a cancer is 1 in 10,000 persons, and 1% of the tests come back positive, then only 1% of the positive tests you get mean that there is a true cancer present. There is also the question of how many cancers are caused by exposing 100 women each year to an X-ray test that is negative (and therefore unnecessary, from the medical point of view)in maybe 90 of them, and a false positive in 8 of them, with attendant biopsies to rule out cancer. All to pick up one or two “real” cancers. You also have to ask would those one or two cancers be found in time to be treated successfully if mammography were delayed by a year, or not? Finally, of the cancers found early, are they all cured, and the patient saved, or are some highly aggressive tumors that kill the patient regardless of the intervention and how early it is applied?
My understanding is that it is a close run thing, when analyzed in that light.
So, I know many irate commentators say “My sister/wife/daughter-in-law’s cancer was found early, and she lived to tell the tale after treatment, it is a life-saver”. And I wonder, if it is such a life-saver, would they be willing to pay for it out of pocket? At that point, it becomes clear that if something that is of marginal value to the group as a whole is paid for by the group, the individual will want the reassurance of a negative test, provided at someone else’s expense. But the group has the right to say, if you want it, and it is so valuable to you to have it, will you pay for it out of your own pocket? At that point, people say, well, maybe it is not worth $200 (or more) out of pocket for a test that is mainly negative.
This is where insurance and third party payment for medical care has corrupted the whole system. Whereas it used to spread manageable risks among large groups of people who made relatively few demands on the system (remember, hospital beds went for $10 per day in the 1940′s and 1950′s), now you literally cannot afford to be sick without insurance these days.
Just so the women don’t feel picked on, the same thing is playing out in men with respect to prostate cancer screening (PSA testing and biopsies). We are beginning to realize that a lot of the positive PSA tests are not cancer, and a lot of the cancers that are found on biopsies are actually rather indolent, and probably are better off not even detected. But there will be some aggressive cancers that really matter, but we are not really clear on who has the bad cancer and who has the not-so-bad cancer (or just prostatitis).
batman,
You could inform the students that by ancient right they all could bring a sheep to graze in the campus commons. The sheep provides both food and clothing, and for some companionship but we won’t go there. Are those not basic necessities of life as much as health care? Who would dare to enclose the commons off and take away such a right? It would be a tragedy. Of course the real Tragedy of the Commons was the destruction caused by free access to what is proclaimed a public good.
Kurt Vonnegut touched on the same theme as L.P. Hartley of PC equality run amok. Why not weigh down thin attractive people with weights and fat suits? KV was a moonbat but he had that right.
Guessed,
Thank you for the technical overview. What would be needed to get 500 Doctors in white coats to go up to Capitol Hill and the White House with butterfly nets? It would do more for the public health than the Public Health Service.
BTW for you both I once knew a charming young lady who was in the PHS and slated to go to a reservation. Sorry I lost track of her.
To be blogged under the title “Equality.”
Josh@39 wrote
“It’s morally repugnant, it seems to me, that we have million-dollar treatments that can fix someone up, but if that someone is a sixty year old day-laborer versus a twenty year old billionaire – should that really determine who gets treatment? Well, it’s going to.”
Why is it morally repugnant? Scarce resources have to be rationed somehow. Is it less morally repugnant to tax the billionaire a million bucks to pay for the day laborers treatment AND deny him care because there is only so much “treatment” to go around? If they are both equally sick why should one automatically get the bill and no treatment?
You are entitled by your Creator to life, liberty, and the pursuit of wealth not to fairness in this world. Maybe in the next that will be rectified.
LOTM @ 45:
From Habu on the last thread came this graphic which just made my jaw drop then made me depressed “..as HELL..“. (Channeling Peanut)
The Decline
I am in much the same boat. No work worth talking about for a year in spite of mucho education with advanced degrees. Well known and talented in my field but that field went to China and the Far East and is not coming back. There is little worth looking at locally. Best thing I can say is this, I will soon have nothing left to lose. And the corruptocrats in DC and the state capital are not helping my state of mind much. The failing health is another issue not helped much by the stress. Trying to fix it but not having much luck. This getting older ain’t for sissies.
Hang in there, things have got to get better or we will have that shooting war. Then……..
As for this health scare reform idiocy, well, the population is getting the government they voted for …… good and hard. It would be nice if they gave The Won his shopping list all at once – healthscare reform (was there anything really broken?), Cap’N Trade destruction of the energy sector (the lights going out or brown and cold will enlighten), the non-Stimulus taxes coming due and then some major city hit hard by al Qaeda (maybe they can take out NYC during the KSM trial? Poetic justice, anyone?). Then come for our guns via the UN (make my day, Shrillary). That should set up the stage nicely. The people will wake up but I hope there is something left.
We’ve been under attack for some time, from multiple fronts. We as in “We the people”…
Sometimes science is politics, it is after all often about money and politics is now more part of it than ever…
…but sometimes, the facade falls down and it is all revealed: Welcome to GlimateGate : The AGW Crime
I’d love to be a fly for just a bit and see faces of Maurice and George and Al in the morning.
#52–Bravo, Guest! Well said.
It’s all fine and good to acknowledge bureaucratic bungling, but there are people who have fallen through the cracks because they are between jobs and can’t afford an extra $1300 a month when unemployment nets them $1600. Even with a second income to help cover a mortgage, insurance, groceries, gasoline, utilities, etc., who can affort such a bill?
Unless we come up with a plan to help those who are hurting through no fault of their own, especially cancer survivors and other high-risk individuals, then, from their perspective, it serves no purpose to simply cast stones at the flawed plans promoted by big government advocates.
The conservatives did little to address the topic during the previous administrations. Now it has come home to roost with a vengeance.
I think that the problem with the current governing class is that the Democrats propose things that will not work, and the Republicans propose nothing, unless they are desperate from being a powerless minority. This is a sad state of affairs.
I would propose the following set of principles to consider for the the reform of health care. Take ‘em or leave ‘em.
First, with respect to people and institutions who provide the services that we call health care, let them set whatever price they wish for whatever service they provide. However, they can only charge that price, or zero. That is, they can have a certain price for a service, but that can’t be different for the person who has insurance and the person in the next bed who doesn’t. If they want to take pity on someone and do it for free, that would be fine, but if it costs $200 to sew up a laceration for Joe the Insured, then it will cost $200 for Jane the Not-Insured in the next bed. Not $120 for Joe, and $600 for Jane. If the provider wants to say “I feel sorry for you, so I will give you a break,” then let it be done for nothing. This principale would hopefully get rid of the phenomenon where the insured patient goes for a service and is charged $1000 for their care, and the uninsured patient is on the hook for $3500 or whatever. This would bring the costs of individual services to some equilibrium that people may not like, but they couldn’t cite the example of the two patients with radically different charges for the exact same treatment.
If a care provider performs a treatment for free for a charity case, let them deduct some multiple of that prospectively set price from their taxes (a deduction or a tax credit). This would greatly encourage provision of indigent care if a heart surgeon could deduct $60,000 from his adjusted gross income if he did a heart operation “worth” $20,000 in terms of his labor to a poor person and could have a real financial subsidy from the government for doing this charitable deed. By the same token, maybe “non-profit” institutions that provide health care and don’t pay taxes should pay taxes on their gross revenues and have the same sort of incentive to provide indigent care as the doctor in the example above. Think about it.
Next, lets REQUIRE that all health care service providers advertise the prices of their services. Yes, require them to advertise. They could provide their fee list for service to the .gov who could do the public the service of posting those prices, and let the consumer shop for a health care provider in part on the basis of price. Yes, make health decisions in part on the basis of what it costs. The consumer could look up what it would cost to fill the prescription at the local pharmacy, and maybe drive a few miles to get the medicine for less. Or not, if the price is competitive. But let the consumer know what it will cost for a gall bladder operation, or a 100 Coumadin pills, or an hour of psychotherapy. In advance of the visit, not as an afterthought when the damage is literally already done. Doctors competing in part on the basis of price? Shocking! No, not really. The myth that providing medical care is some mysterious religious rite (a view that is held by many, and encouraged by, well, doctors, duh!) keeps people from acting in rational ways, when it comes to medical care. Doctors could still distinguish themselves from their competitors on the basis of their bedside manner, reputation for diagnostic acumen, superior surgical skill, etc, and hospitals could compete on the basis of marble lined halls and walnut furniture, or whatever, or offer a cheaper alternative with less frills.
Let any ‘entitlement’ to health care not necessarily correspond to the ability to see an MD about a runny nose, or the high cholesterol. These things can be dealt with quite satisfactorily by a physician’s assistant or a nurse practitioner. Save the more expensive diagnostic or procedural issues for the more highly trained MD.
For the consumer, ban all first dollar coverage of anything, including the “Mom and apple pie” sacred cows of vaccines, or Pap smears, or cholesterol checks, or prenatal care. All of these things have value, and we should not be shy about assigning a fair value to it, based on what people are willing to pay and what providers are willing to take to provide the service. For too long, we have acted like medicine is some sort of sacrament whose price cannot be passed on to the recipient. If something is truly valuable and is of benefit to a patient, then the patient should be made to pay something for that service. The payment from the patient need not be the same for all, but could perhaps be based on some factor times the adjuste gross income, for instance. Maybe I, a fairly wealthy doctor, should pay a fairly high co-payment(maybe $100 for a brief ER visit to get a few stithes for my next table saw accident), and unemployed Bubba could pay something much less ($10 for the same service). This would serve to shift some costs from the poor to me, but not make me the sucker who has to pick up the entire check. This is a fundamental point of equity. If people feel that they are entitled to have unlimited access to expensive things with no skin of their own (figuratively speaking) in the game, it leads to abuse. Not because poor people generally like hanging out int he ER, but because if it is easy to do so, and there is no penalty for getting care in the ER, it is naturally what you will do in lieu of getting a personal physician to take care of you. I remember a man who came to the ER with his wife and two kids at 2 AM when I was a resident in training. He wanted to get tested for gonorrhea. He had no particular shame about acknowledging it right there in front of his wife and kids. I cautiously asked why he came to the ER in the middle of the night, rather than going to a doctor in the civil hours of the day. With no particular shame he said that it was convenient for him to come at that time, and what was my problem. This was at a time when the evolving standard of care was that the patient determined what was an “emergency”, not the doctor or triage nurse. So we have come a long way down that road such that illegals come to the ER for any and all manner of care, and the only way you can seemingly limit the damage is to refuse to feed them.
For the vast majority of patients, their care should be provided under the auspices of private insurance, with stringent regulation by the government. This can take the form of forbidding denial of coverage for pre-existing conditions, and regulated rates for certain basic levels of coverage that can be agreed upon. For people with medical conditions such as cystic fibrosis, or sickle cell anemia, or hemophilia, or in need of transplantation procedures for leukemia or liver failure, etc, let the government “superinsure” their medical care above some lifetime cap; maybe $100,000, or $250,000, or $500,000, whatever (I don’t have a specific number in mind). But the principle would be that people with devastating medical conditions would not be financially destroyed. It is criminal that someone without insurance who has a serious medical problem is forced into bankruptcy through no fault of their own. This would permit private insurance companies to offer lower premiums for standard levels of medical care, with the assurance that for the super-costly, they would be off the hook.
Let the private insurance companies be regulated so that people who are extremely high risk for medical problems be allocated to insurance companies proportional to the number of insured lives they have on their books. That way, the government could play the role of honest broker in terms of assigning each insurance company a proportion of bad risk patients to insure. This could be adjusted so one company couldn’t game the system by cherry picking the healthiest amongst us as their customers. The business model would become competition for the total number of patients and care providers on the basis of how well they serviced claims and what level of services they provide for a given price. They are not doing things that require medical judgement; they are distributing risk and making loans on the basis of future claims. Just like auto insurance.
Let the government grant dispensation to companies to develop common electronic medical records, and coordinate amongst themselves how to ensure security and accuracy without fear of anti-trust implications. The government has some decent systems for electronic medical record keeping that could be put in the public domain. For instance, I have not used it, but the people I know who have used the Veteran’s Administration electronic medical records have all given it good reviews. Let private companies take the .gov systems and build on them, and cooperate amongst themselves to generate a common standard.
Let the data that derives from medical care be deposited in secure databases in anonymous format for evaluation of outcomes to decide what is effective, and what is not effective. Let the decisions about what treatments to cover be based on what works, and what is ineffective. If the consumer wants to obtain a medical treatment that is of marginal effectiveness, or risky, then let them pay for it out of pocket. Enough of the arguments about how the government should pay for something that is not very effective and offers a remote chance of benefit. Let individuals decide if it is worth $40,000 to extend their lives by 5 months when they have cancer at age 40, or 50, or 60, or… It may make sense for the individual, but it may not make sense for a third party (goverment or insurance company) to do it.
Providing greater supply of doctors, nurses, respiratory therapists, dentists, etc: let people get a meaningful subsidy from the government for their time spent studying medicine or their healing art, in return for some time spent in service to the indigent at a fixed salary, or working at the VA or a military medical facility. One year of medical school paid for by .gov could engender a one or two year commitment to work for .gov at a salary comparable to the private sector less some fraction.
Tort reform: no limit on actual damages, but strick limits on “other damages” and the cut administered to the successful plaintiff’s attorney. A doctor or hospital can do an immense amount of damage to a patient, and there is no reason to limit the actual damages assessed. But there is no reason for more than some agreed upon multiple of the actual damages (treble?) for “pain and suffering”, and that could be capped at some prospectively agreed upon amount. The fraction of the damage award to the lawyer could be capped with the same reasoning that applies to capping reimbursement for MDs.
I would hope that a private insurance system that has disincentives for first dollar expenditures, a regulated playing field in terms of insured patient risk and limits on maximum payment to be made could offer much more affordable risk distribution for the average person than we now have.
It would be preferable to what is proposed now, and certainly would not take for than a hundred pages or so to codify.
Just some ideas. You should consider reading two books on this topic by Dr. Nortin Hadler (“Worried Sick” or “The Last Well Man”) for some perspective on why a lot of medical care constitutes “type 2 malpractice” (doing something very competently that didn’t need to be done, as opposed to type 1 malpractice, which is doing something incompetent like cutting off the wrong leg).
guessed,
Thank you, I endorse most of what you say, especially about having one price, or a free deductible waiver, for all customers for a given service performed. Later you seem to alter that position regarding the unemployed Bubba paying something but less rather than full price. No auto service shop can operate without displaying the initial charge to investigate the problem. There is extensive experience with the concept of pricing a fair estimate in many fields. It should always be possible for a Bubba to pay a portion of the full price if a charity separate from whoever owns the examining room or surgery makes up the difference to equal the standard price. I could see schemes to fund charity to Bubba by advertising a set fee and then encourage the full fare retail customer Mr Readycash to make a deductible contribution with some defined benefits. Those could be prettier nurses or access to preferred examination schedules. Maybe the less charitable would get the old hypodermics with the curved metal handles and the square needles.
Back when all doctor were in the AMA and fees were standardized, that is to say fixed, you chose your Dr based on the quality of their National Geographics.
LOTM:
You are right; I am somewhat inconsistent on taking the edge off of the first dollar hit to people paying for health care. I have never been a doctinaire libertarian or free-market proponent (though I would say the free market is the least bad process for allocating resources).
I suppose there are ways to game the system I propose, but it only took me ten minutes to put it out there. How long did it take to write either of the 2,000 page bills we have ready to cram down our throats? And, do you think they won’t be gamed, eventually?
guessed,
How long did it take to write either of the 2,000 page bills we have ready to cram down our throats?
I think the 2,000 pages just floated over the transom or appeared one morning next to the porcelain throne. I think it has less literary merit than a Mickey Spillane novel, that arguably took less time to write than to read. If you dropped it on someone it might qualify as a cheap alternative to the Gas Passer.
Dear Fellow babies,
As usual the discussion has helped clarify things for me, given that, except for my unwilling participation as the unlucky patient, I have no knowledge of medicine. I do have attitude though–I am tired of waking each day wondering/fearing what idiotic plan the Leader will spring next. I think Americans made a * colossal mistake* in the last election. I cannot find words to express my disappointment; I have disagreed with Democrats since about 1975, but until this last 10 months I never realized that how far their vision has veered from mine.
One of my multiple Fears is, that under the coming system, the good doctors will be discouraged by government control of fees, patient traffic, readmissions, growth of the hospital’s operating theaters, etc., and inquiry into physician ownership and compensation of clinics and hospitals. The good doctors, who exercised prudent care and concern for their patients while creating a profitable practice, will swiftly retire; and we will be left with doctors of lesser skill and motivation.
An email to my Senators Warner and Web 11-20-09:
Dear Senator Warner,
please vote NO to S. 1796
I have been working my way through downloaded PDF of HR 3200 since july and now S. 1796. Essentially the same ideas, essentially the same objections. The health care plan creates agencies and layers of administrators and bureaucrats far in excess of any earthly necessity; It’s like an army of consisting of 50,000 enlisted to fight, and 3 million officers to coordinate from the rear. Western philosophy, science, and existing law has served to provide the best health care system and the most productive medical research industries in the world. Health care delivery is supposed to be the specific justification for this bill. But Obviously it is Not. The whole point of this bill is Tax Delivery; is Sanctions and Penalties Delivery; is vastly bloated bureaucracy delivery. It is not able to provide better medicine or better doctors; it just takes the same resources, spreads them a little thinner, puts boatloads of bureaucracies in charge of most decisions, taxes everyone excessively, rations medicine and procedures based on actuarial age/outcomes, and eventually discards the husk of worker-citizens that are no longer productive.
The new Health Choices agency with it’s intrusive inspections, mandated audits of the owner’s accounts, audits to survey for compliance in the management of employee health, etc. are guaranteed to insure that private insurance companies and the small businesses that support them will be extinguished. Health Insurance has been part of the wage benefits package that has been administered successfully for about 75 years, and doesn’t need fixing. But the federalized health care system will impose 5 agencies -the new Health Choices Agency, Health and Human Services, Labor, Treasury, and the IRS to inspect and audit businesses for compliance and sanctions. There is no provision that they combine audit teams in a single group for a coordinated effort —- no. When will a business owner find time to conduct normal business functions dealing with as many as five or more audits yearly?
I believe the excessive auditing and penalties will finally drive small business to jettison it’s employee health care packages; eventually even big insurance companies may die off, and the government will have to increase taxes to pay for the millions of workers displaced from the insurance industry. After adding all the poor and indigent with no health insurance at the beginning of the program, the plan will destroy many business by eliminating the environment and the service opportunity they fulfilled; and it will eliminate many more by taxing and penalizing the owners to the point they have no incentive to continue operating. These people will join the ranks of the Poor –whose taxes will pay for workers whose industry has disappeared?
This bill is long on ideology, taxation, and coercion, but short on economics and and intelligence.
Please vote NO to S. 1796
Thanks, /Real Name Here
I feel pretty good now, I enjoyed writing this; I just hope I’ll still think it was a good idea when they’re stretching me on the rack.
I think that the problem with the current governing class is that the Democrats propose things that will not work, and the Republicans propose nothing, unless they are desperate from being a powerless minority. This is a sad state of affairs.
So true.
Reid bill:
16M uninsured U.S. citizens pay a penalty tax.
8M uninsured illegal aliens do not.
Under Leader Reid’s amendment, in the year 2019 about 16 million U.S. citizens would be uninsured and be forced to pay a penalty tax of almost $800 per year.
About eight million illegal aliens would be uninsured and would owe no penalty tax. Both groups would get their health care through a combination of out-of-pocket spending and use of uncompensated care in emergency rooms and free health clinics.
Fair’s Fair!
—
“As in every industry dominated by monopolies, innovation will shrivel.
The medical equivalent of more chrome and styling will be trotted out each year over the same old chassis.”
…but us Land Shark’s will still have fins!
David S. Broder Deconstructs Obamacare!